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In today's podcast, Meghann Drella, one of the Senior Solutions Managers with Outsource Strategies International discusses how to report critical care services.

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Hello and Welcome to our Podcast series. My name is Meghann Drella and I am a Senior Solutions Manager here at Outsource Strategies International. Today, I will be discussing how to report critical care services.

While reporting critical care services, physicians document medical necessity to ensure that the patient understands the definition of critical care.

Critical care medicine specialists diagnose and treat a wide variety of diseases. A multidisciplinary team approach is needed to care for critically ill patients. Though there are only two codes for critical care services, reporting critical care presents a challenge because of the rules and regulations involved. In fact, Medicare and commercial payers scrutinize the manner in which critical care services are billed. Documentation of medical necessity is crucial.

Critical care services are the professional services provided to patients with a critical illness or injury. To report the services accurately, it is necessary to understand what constitutes critical care.

Both CPT and Medicare have provided definitions of critical care. According to CPT 2017, “Critical care is the direct delivery by a physician(s) or other qualified health care professional of medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition. Critical care involves high complexity decision making to assess, manipulate, and support vital system function(s) to treat single or multiple vital organ system failure and/or to prevent further life-threatening deterioration of the patient's condition.”

Medicare and other payers add that critical care should be medically necessary as “the failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life threatening deterioration in the patient’s condition.”

Medical necessity is defined by Medicare as “health care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.” The documentation must clearly convey the reasons why the diagnostic and treatment decisions were made.

Common conditions that require critical care are:

  • Heart problems
  • Lung problems
  • Organ failure
  • Brain trauma
  • Blood infections
  • Drug-resistant infections
  • Serious injuries

How can a practitioner decide what constitutes critical care? The Society of Critical Care Medicine (SSCM) cautions that when reporting services, physicians should ensure that the patient meets the definition of critical care. There are many instances where the patient may be in the critical care unit, but does not meet the critical care criteria.  For instance, a patient receiving chronic ventilation in the critical care unit may not be considered critical unless they meet the critical care definition.

To report the critical care codes, the physician’s document must support the critical care claim with details such as the patient’s condition, services provided, time spent rendering care, and any other relevant information.

Physicians must also know when time involved with family members or other surrogate decision makers may be counted toward critical care.

When it comes to critical care services, the red flags that will attract the attention of insurance carrier auditors are inaccurate coding, insufficient or lack of documentation, non adherence to payer policies, and lack of medical necessity. Unbundling procedures included in critical care or overuse of modifiers can also trigger an audit. The following best practices can reduce risk of payer audits:

-           Ensure accurate and up-to-date CPT and ICD-10 codes in claims.

-           Provide comprehensive documentation

-           Be familiar with Medicare and private payer rules and policies on billing critical care services.

-           Make sure documentation can support medical necessity for all billed services.

-           Avoid overutilization of critical care services

I hope this helps, but always remember that documentation requires thorough knowledge of payer regulations and guidelines is critical to ensure accurate reimbursement for the procedures performed.

Thank You for joining me and stay tuned for my next podcast.